Chapter One
Foundations of Psychiatric Mental Health Nursing
Mental Health
● The WHO defines health as a state of complete physical, mental, and social
wellness, not merely the absence of disease or infirmity.
● Mental health is influenced by individual factors, including biologic makeup,
autonomy, and independence, self-esteem, capacity for growth, vitality, ability to
find meaning in life, resilience or hardiness, sense of belonging, reality
orientation, and coping or stress management abilities; by interpersonal factors,
including effective communication, helping others, intimacy, and maintaining a
balance of separateness and connectedness; and by social/cultural factors,
including sense of community, access to resources, intolerance of violence,
support of diversity among people, mastery of the environment, and a positive yet
realistic view of the world (damn, that was a mouthful!).
Mental Illness
● The APA (2000) defines a mental disorder as “a clinically significant behavioral
or psychological syndrome or pattern that occurs in an individual and that is
associated with present distress or disability or with a significantly increased risk
of suffering death, pain, disability, or an important loss of freedom”.
● Deviant behavior does not necessarily indicate a mental disorder.
Diagnostic and statistical manual of mental disorders
● The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR
describes all mental disorders, outlining specific criteria for each based on clinical
experience and research.
● The DSM-IV-TR has 3 purposes:
○ To provide standardized nomenclature and language for all mental health
professionals.
○ To present defining characteristics or symptoms that differentiates specific
diagnoses.
○ To assist in identifying the underlying causes of disorders.
● A multiaxial classification system that involves assessment on several axes, or
domains of information, allows the practitioner to identify all the factors that
relate to a persons condition.
○ Axis I is for identifying all major psychiatric disorders except MR and
personality disorders. Examples include depression and schizophrenia.
○ Axis II is for reporting mental retardation and personality disorders as well
as prominent maladaptive personality features and defense mechanisms.
○ Axis III is for reporting current medical conditions that are potentially
relevant to understanding or maintaining the person’s mental disorder as
well as medical conditions that might contribute to understanding the
person.
○ Axis IV is for reporting psychosocial and environmental problems that
may affect the diagnosis, treatment, and prognosis of mental disorders.
Included are problems with the primary support group, the social
environment, education, occupation, housing, economics, access to health
care, and the legal system.
Compiled By: Bheru Lal Page 43
, ○ Axis V presents a Global Assessment of Functioning which rates the
person’s overall psychological functioning on a scale of 0 to 100. This
represents the clinician’s assessment of the person’s current level of
functioning.
● All clients admitted to a hospital or psychiatric treatment will have a multiaxis
diagnosis from the DSM-IV-TR.
Period of Enlightenment and Creation of Mental Institutions
● In the 1790’s Phillippe Pinel in France and Willian Tukes of England formulated
the concept of asylum as a safe refugee or haven offering protection at
institutions where people had been beaten, whipped, and starved for their mental
illness.
● In the US, Dorothea Dix (1802-1887) began a crusade to reform the treatment of
mental illness after a visit to the Tukes’ institution in England. She was
instrumental in opening 32 state hospitals that offered asylum to the suffering.
● 100 years after establishment of the first asylum, state hospitals were in trouble.
Attendants were accused of abusing the residents, the rural locations of the
hospitals were viewed as isolating patients from their families and homes, and the
phrase insane asylum took on a negative connotation.
Development of Psychopharmacology
● In the 1950’s the development of psychotropic drugs were used to treat mental
illness.
● Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic
agent, were the first drugs to be developed.
● 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an
antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines),
were introduced.
● Because of these new drugs, hospital stays were shortened, and many people were
well enough to go home.
Move toward Community Mental Health
● The enactment of the Community Mental Health Centers Act came about in 1963.
● Deinstitutionalization, a deliberate shift from institutional care in state hospitals
to community facilities, began.
● In addition to deinstitutionalization, federal legislation was passed to provide an
income for disabled persons: SSI and SSDI. This allowed people with mental
illnesses to be more independent financially and not to rely on family for money.
Mental Illness in the 21st Century
● The Department of Health and Human Services (DHHS) estimates that 56 million
Americans have a diagnosable mental illness.
● The term Revolving door effect is used to explain how people with severe and
persistent mental illness have shorter hospital stays, but they are admitted more
frequently. People with severe and persistent mental illness may show signs of
improvement in a few days but are not stabilized. Thus, they are discharged into
the community without being able to cope with community living. Substance
abuse issues cannot be dealt with in the 3-5 days typical for admissions in the
current managed care environment.
● Many providers believe today’s clients are to be more aggressive than those in the
past. Between 4% and 8% in clients seem in Psychiatric ER’s are armed. People
Compiled By: Bheru Lal Page 43
, not receiving adequate mental health care commit about 1,000 homicides each
year.
● In state prisons, 1 in 10 prisoners take psychotropic medications and 1 in 8
receives counseling or therapy for mental health issues.
● 85% of the homeless population has a psychiatric illness and/or a substance abuse
problem.
● The United States has the largest percentage of mentally ill citizens (29.1%) and
provided care for only 1 in 3 people who needed it (Bijl et al., 2003).
● Persons with minor or mild cases are most likely to receive treatment while those
with severe and persistent mental illness were least likely to be treated.
Cost containment and managed care
● Managed Care is a concept designed to purposely control the balance between
the quality of care provided and the cost of that care. In a managed care system,
people receive care based on need rather than request.
● Case management or management of care on a case-by-case basis represented an
effort to provide necessary services while containing costs. The client is assigned
a case manager, a person who coordinates all types of care needed by the client.
● In 1996, Congress passed the Mental Health Parity Act, which eliminated annual
and lifetime dollar amounts for mental health care for companies with more than
50 employees. However, substance abuse was not covered by this law, and
companies could limit the number of days in the hospital or the number of clinic
visits per year. Thus, parity did not really exist.
Psychiatric Nursing Practice
● In 1873, Linda Richards improved nursing care in psychiatric hospitals and
organized educational programs in state mental hospitals in Illinois. Richards is
called the first American psychiatric nurse.
● The first training of nurses to work with persons with mental illness was in 1882.
The care focused on nutrition, hygiene and activity. Nurses adapted medical-
surgical principles to the care of clients with psychiatric disorders and treated
them with tolerance and kindness.
● Treatments such as insulin shock therapy (1935), psychotherapy (1936), and
electroconvulsive therapy (1937) required nurses to use their medical skills more
extensively.
● John Hopkins was the first school of nursing to include a course on psychiatric
nursing in its curriculum.
● In 1950, the National League for Nursing (which accredits nursing programs)
required schools to include an experience in psychiatric nursing.
● In 1973, the ANA developed Standards of care, which states the responsibilities
for which nurses are accountable.
● Psychiatric nursing practice has been profoundly influenced by Hildegard Peplau
and June Mellow, who wrote about the nurse-client relationship, anxiety, nurse
therapy, and interpersonal nursing therapy.
Psychiatric Mental Health Nursing Phenomena of Concern
● The maintenance of optimal health and well-being and the prevention of
psychobiologic illness.
● Self-care limitations or impaired functioning related to mental and emotional
distress.
Compiled By: Bheru Lal Page 43
, ● Deficits in the functioning of significant biologic, emotional, and cognitive
symptoms.
● Emotional stress or crisis components if illness, pain, and disability.
● Self-concept changes, developmental issues, and life process changes.
● Problems related to emotions such as anxiety, anger, sadness, loneliness, and
grief.
● Physical symptoms that occur along with altered psychological functioning.
● Alterations in thinking, perceiving, symbolizing, communicating, and decision
making.
● Difficulties relating to others
● Behaviors and mental states that indicate the client is a danger to self or others or
has a significant disability.
● Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances
or events that affect the mental or emotional well-being of the individual, family,
or community.
● Symptom management, side effects/toxicities associated with
psychopharmacologic intervention, and other aspects of the treatment regimen.
Standards of Psychiatric mental health clinical nursing practice.
● Standard I. Assessment
○ The psychiatric-mental health nurse collects health data
● Standard II. Diagnosis
○ The psychiatric-mental health nurse analyzes the data in determining
diagnoses.
● Standard III. Outcome identification.
○ The psychiatric-mental health nurse identifies expected outcomes
individualized to the client.
● Standard IV. Planning.
○ The psychiatric-mental health nurse develops a plan of care that prescribes
interventions to attain expected outcomes.
● Standard V. Implementation
○ The psychiatric-mental health nurse implements the interventions
identified in the plan of care.
● Standard Va. Counseling
○ The psychiatric-mental health nurse uses counseling interventions to assist
clients in improving or regaining their previous coping abilities, fostering
mental health, and preventing mental illness and disability.
● Standard Vb. Milieu Therapy
○ The psychiatric-mental health nurse provides structures, and maintains a
therapeutic environment in collaboration with the client and other health
care practitioners.
● Standard Vc. Self-care activities.
○ The psychiatric-mental health nurse structures interventions around the
client’s activities of daily living to foster self-care and mental and physical
well-being.
● Standard Vd. Psychobiologic Interventions.
○ The psychiatric-mental health nurse uses knowledge of psychobiologic
interventions and applies clinical skills to restore the client’s health and
prevent further disability.
Compiled By: Bheru Lal Page 43
Foundations of Psychiatric Mental Health Nursing
Mental Health
● The WHO defines health as a state of complete physical, mental, and social
wellness, not merely the absence of disease or infirmity.
● Mental health is influenced by individual factors, including biologic makeup,
autonomy, and independence, self-esteem, capacity for growth, vitality, ability to
find meaning in life, resilience or hardiness, sense of belonging, reality
orientation, and coping or stress management abilities; by interpersonal factors,
including effective communication, helping others, intimacy, and maintaining a
balance of separateness and connectedness; and by social/cultural factors,
including sense of community, access to resources, intolerance of violence,
support of diversity among people, mastery of the environment, and a positive yet
realistic view of the world (damn, that was a mouthful!).
Mental Illness
● The APA (2000) defines a mental disorder as “a clinically significant behavioral
or psychological syndrome or pattern that occurs in an individual and that is
associated with present distress or disability or with a significantly increased risk
of suffering death, pain, disability, or an important loss of freedom”.
● Deviant behavior does not necessarily indicate a mental disorder.
Diagnostic and statistical manual of mental disorders
● The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR
describes all mental disorders, outlining specific criteria for each based on clinical
experience and research.
● The DSM-IV-TR has 3 purposes:
○ To provide standardized nomenclature and language for all mental health
professionals.
○ To present defining characteristics or symptoms that differentiates specific
diagnoses.
○ To assist in identifying the underlying causes of disorders.
● A multiaxial classification system that involves assessment on several axes, or
domains of information, allows the practitioner to identify all the factors that
relate to a persons condition.
○ Axis I is for identifying all major psychiatric disorders except MR and
personality disorders. Examples include depression and schizophrenia.
○ Axis II is for reporting mental retardation and personality disorders as well
as prominent maladaptive personality features and defense mechanisms.
○ Axis III is for reporting current medical conditions that are potentially
relevant to understanding or maintaining the person’s mental disorder as
well as medical conditions that might contribute to understanding the
person.
○ Axis IV is for reporting psychosocial and environmental problems that
may affect the diagnosis, treatment, and prognosis of mental disorders.
Included are problems with the primary support group, the social
environment, education, occupation, housing, economics, access to health
care, and the legal system.
Compiled By: Bheru Lal Page 43
, ○ Axis V presents a Global Assessment of Functioning which rates the
person’s overall psychological functioning on a scale of 0 to 100. This
represents the clinician’s assessment of the person’s current level of
functioning.
● All clients admitted to a hospital or psychiatric treatment will have a multiaxis
diagnosis from the DSM-IV-TR.
Period of Enlightenment and Creation of Mental Institutions
● In the 1790’s Phillippe Pinel in France and Willian Tukes of England formulated
the concept of asylum as a safe refugee or haven offering protection at
institutions where people had been beaten, whipped, and starved for their mental
illness.
● In the US, Dorothea Dix (1802-1887) began a crusade to reform the treatment of
mental illness after a visit to the Tukes’ institution in England. She was
instrumental in opening 32 state hospitals that offered asylum to the suffering.
● 100 years after establishment of the first asylum, state hospitals were in trouble.
Attendants were accused of abusing the residents, the rural locations of the
hospitals were viewed as isolating patients from their families and homes, and the
phrase insane asylum took on a negative connotation.
Development of Psychopharmacology
● In the 1950’s the development of psychotropic drugs were used to treat mental
illness.
● Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic
agent, were the first drugs to be developed.
● 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an
antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines),
were introduced.
● Because of these new drugs, hospital stays were shortened, and many people were
well enough to go home.
Move toward Community Mental Health
● The enactment of the Community Mental Health Centers Act came about in 1963.
● Deinstitutionalization, a deliberate shift from institutional care in state hospitals
to community facilities, began.
● In addition to deinstitutionalization, federal legislation was passed to provide an
income for disabled persons: SSI and SSDI. This allowed people with mental
illnesses to be more independent financially and not to rely on family for money.
Mental Illness in the 21st Century
● The Department of Health and Human Services (DHHS) estimates that 56 million
Americans have a diagnosable mental illness.
● The term Revolving door effect is used to explain how people with severe and
persistent mental illness have shorter hospital stays, but they are admitted more
frequently. People with severe and persistent mental illness may show signs of
improvement in a few days but are not stabilized. Thus, they are discharged into
the community without being able to cope with community living. Substance
abuse issues cannot be dealt with in the 3-5 days typical for admissions in the
current managed care environment.
● Many providers believe today’s clients are to be more aggressive than those in the
past. Between 4% and 8% in clients seem in Psychiatric ER’s are armed. People
Compiled By: Bheru Lal Page 43
, not receiving adequate mental health care commit about 1,000 homicides each
year.
● In state prisons, 1 in 10 prisoners take psychotropic medications and 1 in 8
receives counseling or therapy for mental health issues.
● 85% of the homeless population has a psychiatric illness and/or a substance abuse
problem.
● The United States has the largest percentage of mentally ill citizens (29.1%) and
provided care for only 1 in 3 people who needed it (Bijl et al., 2003).
● Persons with minor or mild cases are most likely to receive treatment while those
with severe and persistent mental illness were least likely to be treated.
Cost containment and managed care
● Managed Care is a concept designed to purposely control the balance between
the quality of care provided and the cost of that care. In a managed care system,
people receive care based on need rather than request.
● Case management or management of care on a case-by-case basis represented an
effort to provide necessary services while containing costs. The client is assigned
a case manager, a person who coordinates all types of care needed by the client.
● In 1996, Congress passed the Mental Health Parity Act, which eliminated annual
and lifetime dollar amounts for mental health care for companies with more than
50 employees. However, substance abuse was not covered by this law, and
companies could limit the number of days in the hospital or the number of clinic
visits per year. Thus, parity did not really exist.
Psychiatric Nursing Practice
● In 1873, Linda Richards improved nursing care in psychiatric hospitals and
organized educational programs in state mental hospitals in Illinois. Richards is
called the first American psychiatric nurse.
● The first training of nurses to work with persons with mental illness was in 1882.
The care focused on nutrition, hygiene and activity. Nurses adapted medical-
surgical principles to the care of clients with psychiatric disorders and treated
them with tolerance and kindness.
● Treatments such as insulin shock therapy (1935), psychotherapy (1936), and
electroconvulsive therapy (1937) required nurses to use their medical skills more
extensively.
● John Hopkins was the first school of nursing to include a course on psychiatric
nursing in its curriculum.
● In 1950, the National League for Nursing (which accredits nursing programs)
required schools to include an experience in psychiatric nursing.
● In 1973, the ANA developed Standards of care, which states the responsibilities
for which nurses are accountable.
● Psychiatric nursing practice has been profoundly influenced by Hildegard Peplau
and June Mellow, who wrote about the nurse-client relationship, anxiety, nurse
therapy, and interpersonal nursing therapy.
Psychiatric Mental Health Nursing Phenomena of Concern
● The maintenance of optimal health and well-being and the prevention of
psychobiologic illness.
● Self-care limitations or impaired functioning related to mental and emotional
distress.
Compiled By: Bheru Lal Page 43
, ● Deficits in the functioning of significant biologic, emotional, and cognitive
symptoms.
● Emotional stress or crisis components if illness, pain, and disability.
● Self-concept changes, developmental issues, and life process changes.
● Problems related to emotions such as anxiety, anger, sadness, loneliness, and
grief.
● Physical symptoms that occur along with altered psychological functioning.
● Alterations in thinking, perceiving, symbolizing, communicating, and decision
making.
● Difficulties relating to others
● Behaviors and mental states that indicate the client is a danger to self or others or
has a significant disability.
● Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances
or events that affect the mental or emotional well-being of the individual, family,
or community.
● Symptom management, side effects/toxicities associated with
psychopharmacologic intervention, and other aspects of the treatment regimen.
Standards of Psychiatric mental health clinical nursing practice.
● Standard I. Assessment
○ The psychiatric-mental health nurse collects health data
● Standard II. Diagnosis
○ The psychiatric-mental health nurse analyzes the data in determining
diagnoses.
● Standard III. Outcome identification.
○ The psychiatric-mental health nurse identifies expected outcomes
individualized to the client.
● Standard IV. Planning.
○ The psychiatric-mental health nurse develops a plan of care that prescribes
interventions to attain expected outcomes.
● Standard V. Implementation
○ The psychiatric-mental health nurse implements the interventions
identified in the plan of care.
● Standard Va. Counseling
○ The psychiatric-mental health nurse uses counseling interventions to assist
clients in improving or regaining their previous coping abilities, fostering
mental health, and preventing mental illness and disability.
● Standard Vb. Milieu Therapy
○ The psychiatric-mental health nurse provides structures, and maintains a
therapeutic environment in collaboration with the client and other health
care practitioners.
● Standard Vc. Self-care activities.
○ The psychiatric-mental health nurse structures interventions around the
client’s activities of daily living to foster self-care and mental and physical
well-being.
● Standard Vd. Psychobiologic Interventions.
○ The psychiatric-mental health nurse uses knowledge of psychobiologic
interventions and applies clinical skills to restore the client’s health and
prevent further disability.
Compiled By: Bheru Lal Page 43
